Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0005 can be found here:

Documents and Forms

Document Name Document Type
Form LS-276 Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions Form
LS-276 Application for Security Deposit Determination LS-276(1).pdf www.dol.gov/owcp/dlhwc/LS-276.pdf Form
LS-275(IC) Agreement and Undertaking (Insurance Carrier) LS-275ic(1).pdf www.dol.gov/owcp/dlhwc/LS-275ic.pdf Form
LS-275(SI) Agreement and Undertaking (Self-Insured Employer) LS-275si(1).pdf www.dol.gov/owcp/dlhwc/LS-275si.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.210 20 CFR 703.203 20 CFR 703.303 20 CFR 703.209 20 CFR 703.205 20 CFR 703.204 20 CFR 703.212 20 CFR 703.304

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-276	Application for Security Deposit Determination	LS-276(1).pdf	http://www.dol.gov/owcp/dlhwc/LS-276.pdf	Yes	No	Fillable Printable
Form	LS-275(IC)	Agreement and Undertaking (Insurance Carrier)	LS-275ic(1).pdf	http://www.dol.gov/owcp/dlhwc/LS-275ic.pdf	Yes	No	Fillable Printable
Form	LS-275(SI)	Agreement and Undertaking (Self-Insured Employer)	LS-275si(1).pdf	http://www.dol.gov/owcp/dlhwc/LS-275si.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-3, DOL/OWCP-4	FR Citation: 81 FR 25765

Number of Respondents: 695	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	695	0	9	686
Annual IC Time Burden (Hours)	869	390	7	472
Annual IC Cost Burden (Dollars)	16,152	15,749	60	343

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.